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Audits for health care providers face different obstacles, depending on the type of health care they are providing as well as where the audit came from. Overpayment allegations can be made by several different Medicaid and Medicare audit contracts including Recovery Audit Contractors (RACs)and Medicaid Integrity Contractors (MICs).
These contractors have the objective of finding overpayment and fraudulent behavior by these health care providers and they each have a different way to audit an individual process. Because of this, providers can’t assume that because they have had an audit in the past that the approaching a new audit will be the correct way to proceed. Each contractor has their own audit process and they can also be different in what financial incentives they need to push for as their maximum recovery amounts. The contractors that receive compensation based on how much of the amount they recover will be less interested in negotiating than those that receive a flat fee.
Our attorneys are highly experienced and proficient in handling all forms of audits. Our attorneys have a tried and true strategic approached that we developed to each different type of audit based on vast knowledge and experience. Based on the unique details of your case, we can develop a plan of action to most effectively defend against the allegations you face.
As a part of the effort to find and prevent Medicaid fraud, the Medicaid Integrity Program (MIP) was created and their audits are designed to detect fraud and errors and ultimately recoup any overpayments. MIP is executed by several Medicaid Integrity Contractors (MICs) who conduct the reviews and audits that help to identify and recoup any improper payments. These MIC’s act with the Medicaid agency in each state and provide oversight and technical aid. The requirements of the MIP allow CMS to hire MICs to review the claims and conduct the audits as well as to educate providers about the proper Medicaid claims compliance.
The MICs are split into three different types depending on what their main task is:
• Review MIC’s
• Education MIC’s
• Audit MIC’s
The review MIC’s identify providers that need to be audited and any potential reviewing claims that were submitted at least five years back.
The audit MIC then takes over the case and informs the provider with a notice of the audit and then requests records. In the early part of the audit, the provider will have an initial meeting with the audit MIC and it can then be determined if it is a field audit or a desk audit. In the early stages of the audit, the provider will also have an entrance conference with the audit MIC.
After the audit is finished, the audit MIC will submit a draft of the audit to the state Medicaid agency that will then review it and makes comments on whether the Medicaid policies in the state were followed correctly. After that, the report is forwarded to the provider who has 30 days to submit any additional comments or information within 30 days.
MIC’s are not compensated like RAC’s so they are not paid on a contingency basis and don’t even collect the overpayments. When the overpayments have been identified, the state will take over collecting the amount due from the providers and then the federal government gets its share directly from the state. State law governs any of the appeals from an MIC audit determination. Medicaid fraud, if found, can be criminally prosecuted either from the result of an audit or an investigation by the state or federal government.
Audits and appeals in Medicaid cases can involve many complex interactions of the state and federal law. Our attorneys are high experience in effectively negotiating the many complex laws to receive a successful outcome. Medicaid overpayment and fraud allegations can include criminal prosecution, fines, civil suits and also exclusion from the Medicare and Medicaid program.
Audits for Medicare focus on payment for service that were actually performed by the health care provider and that all service met the Medicare coverage conditions as well as were medically necessary. Genuine fraud does not need to be committed for an audit to occur. Mistakes in complicated paperwork or misinterpretation of contracts provisions as well as conflicting opinions on what medically necessary means can cause an audit to occur.
Health care providers that try to handle audits on their own often think that they didn’t do anything wrong so it should be easy to fix without help find that the audit process is very complicated. It’s important to contact an attorney to walk you through the many steps of an audit so that there aren’t any mistakes that cause you to lose resources and money while the audit process continues on. Our attorneys also know that many of the CMS contractors are paid based on how much money they recover so they have less interest in negotiating and will want to recover as much of the funds as possible.
Our attorneys can offer assistance to a health care provider at any step of an audit. Whether you were just notified of an audit or you are in the appeal stage, our attorneys can assess your case and come up with an individualized approach. Our highly qualified attorneys have extensive experience audits and appeals to help you get the most successful outcome possible.